A Case Study in Applied Ethics

In my professional life, one of the things I frequently have to do is tell someone that I am recommending a course of action that they may not be terribly keen on pursuing. And I know it when I am making the recommendation. "I'm sorry, sir, but I think we are going to need to admit you to the hospital/put this tube in your chest/cut off the remainder of your finger," etc. I am accustomed to getting resistance in these situations and having to convince the patient that there's a good reason to do what I recommend. Usually, patients exhibit good sense and comply. Sometimes they refuse. Generally, I am OK with that. It's the right of a patient to refuse treatment they don't want. I don't take it personally, but it can be a bit frustrating when you have to watch someone make a really bad decision.

But it does bring up an interesting and tricky issue: when is a patient NOT allowed to refuse care?

We had an illustrative and complex case recently along these lines. A young man, in his early 20s, was seen in the ER on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures. In each case he was felt not to be eligible for detainment under our state's law (which sets a fairly high bar for involuntary treatment compared to many other states), and he was able to "contract for safety," for whatever that is worth, and so was released each time. A complicated overlying factor was his heavy dependence on opiates and benzodiazepines.

He returned to the ER following a motor vehicle accident. It was a single-vehicle accident where his car had left the road and hit a tree for no apparent reason. He appeared sleepy on the scene and roused with narcan pre-hospital; the medics assumed that he crashed because he was stoned. In the ER, he admitted taking some pills to get high, and admitted that he still felt somewhat suicidal, but denied that he was trying to kill himself by crashing his car. The urine toxicology test was positive for opiates and benzodiazepines, but a blood alcohol was negative.

He did have multiple injuries -- several broken ribs and pulmonary contusions and a small cerebral contusion. While he was in the ER, his oxygenation began to deteriorate and a repeat chest x-ray showed increased opacification, suggesting worsening pulmonary contusions/incipient ARDS.

I explained that he was going to require intubation and mechanical ventilation due to the severity of his lung injuries. He refused.

For those familiar with trauma, the early signs of hypoxia and worsening x-ray findings indicate a really bad lung injury which absolutely will require ventilatory support as a life-saving measure. There are not really any other compromise treatment options, at least none that offer reasonable expectations of making a difference.

At this time, the patient was alert and seemingly oriented. He was able to express that he understood that refusing intubation would lead to his death. He was unable to, or chose not to, articulate any reason that he did not want to be intubated. He stated to multiple people that he was comfortable with the idea of dying, and he felt at peace. He was adamant in his refusal of intubation.

At the time these discussions took place, he had received some pain medicine for the rib fractures. His oxygenation was borderline low at 89% on high-flow oxygen, but vital signs were otherwise more or less stable. No family was available. After some time in the ED, his oxygen levels began to decline further and the patient was no longer verbally responsive.

To summarize, this young man, with a long life ahead of him, has a lethal injury for which he has clearly refused the only potential life-saving intervention. He has demonstrated the bare minimum elements of an informed refusal of care, and has done so consistently to multiple interviewers. However, his decision-making may have been compromised by his head injury, by low oxygen levels, or by the presence of intoxicants (both recreational and therapeutic). Other complicating factors include his latent suicidal ideation and speculation as to whether his injury may have been self-inflicted.

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Would it make a difference in your decision if you were told the survival rate for this injury was only 25% even with full treatment?

Would it make a difference if the patient were 75 instead of 25?

Does the possibility that he may have been suicidal invalidate his refusal of care?

Let me know what you think in the comments, and I'll fill in the outcome in a couple of days.

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